COVID-19 DAILY SYMPTOM MONITORING TOOL

Complete for contact of a confirmed Coronavirus disease 2019 (COVID-19) case

Details of health official completing this Date completing
Details of contact of confirmed case (details of case completed just before instructions) DD/MM/YYYY
form form
Date of Place last
NICD Identifier DD/MM/YYYY Surname Name
contact contact
Surname Name Role Facility name
Date of birth DD/MM/YYYY Age (Y) Sex MF Email address Telephone number

Healthcare
YN If yes, facility name
worker Next of kin details
Contact Next of Kin name and Next of Kin contact
Email
number(s) surname number
Physical address
House
Street Suburb Town
number
District Province Patient traced YN
Details of confirmed COVID-19 case
NICD
Contact type1 Close  Casual  Relation to case2 Surname DOB DD/MM/YYYY
identifier

Instructions for completion: Instructions for completion: Mark “Y” if symptom present and “N” if not. If any symptoms are present collect, contact 082 883 9920 immediately and make
immediate arrangements for the collection of a combined nasopharyngeal and oropharyngeal swab. Refer to COVID-19 Quick Guide on the NICD website for additional details. Days post
exposure to case.
DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Date (DD/MM)
Measured body temp
Chills YN YN YN YN YN YN YN YN YN YN YN YN YN YN
Cough YN YN YN YN YN YN YN YN YN YN YN YN YN YN
Sore throat YN YN YN YN YN YN YN YN YN YN YN YN YN YN
Shortness of breath YN YN YN YN YN YN YN YN YN YN YN YN YN YN
Myalgia/body pains YN YN YN YN YN YN YN YN YN YN YN YN YN YN
3
Diarrhoea YN YN YN YN YN YN YN YN YN YN YN YN YN YN
1 Close contact: A person having had face-to-face contact (≤2 metres) or was in a closed environment with a COVID-19 case; this includes, amongst others, all persons living in the same household as a COVID-19 case and, people working
closely in the same environment as a case. A healthcare worker or other person providing direct care for a COVID-19 case, while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified
disposable N95 respirator, eye protection). A contact in an aircraft sitting within two seats (in any direction) of the COVID-19 case, travel companions or persons providing care, and crew members serving in the section of the aircraft
where the index case was seated. Casual contact: Anyone not meeting the definition for a close contact but with possible exposure. 2 Chose from: Spouse, Aunt, Child, Class mate, Colleague, Cousin, Father, Friend, Grandfather,
Grandmother, Healthcare worker taking care of, Mother, Nephew, Niece, Other relative, Uncle. 3 Diarrhoea defined as three or more loose stools in a 24-hour period.

Page 1 of 1 Version 6, 14 February 2020